The Journal of orthopaedic and sports physical therapy. Brooks JH, Fuller CW, Kemp SP, Reddin DB. Diagnosis can be confirmed with MRI. (2, 4, 5) The type I, or high-speed running injuries have been reported to take a mean of 16 weeks to return to pre-injury level of performance in a study of elite sprinters. Nicholson et al reported that for fluoroscopically-guided corticosteroid injections, there was a significant improvement in pain score and level of athletic participation at 21 months. Hamstring strain is a well-documented problem within both the amateur and professional sporting populations. Ultrasound. Heiser TM, Weber J, Sullivan G, Clare P, Jacobs RR. Each reviewer extracted relevant data into appraisal forms, with the primary reviewer then transcribing data into a purpose-built Microsoft Office Excel file. The hip and knee are flexed to end range and then the knee is passively extended. (60) The PRP injections in this study were performed using direct palpation without image-guidance. Numerous potential risk factors for hamstring strain injury were investigated in the identified literature. Despite research interest, knowledge of risks for and management of hamstring strain is limited, as evidenced by high injury rates. Moen et al reported that self-reported time to return to play and passive straight leg raise deficit were significantly associated with time to return to play after hamstring injury. Connell DA, Schneider-Kolsky ME, Hoving JL, et al. According to authors' knowledge there is limited evidence regarding . Wong MW, Tang YN, Fu SC, Lee KM, Chan KM. (38) Some studies have shown that cross sectional area and length are directly related to time away from sport. Type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. Achilles allograft has shown comparable results to acute repairs in small studies. Most of the literature was of moderate quality, but inadequate sample description was common, as was a lack of sample size justification. Conservative interventions were most frequently investigated, but surgical interventions were reported. Moreover, the risk may differ among athletes of different playing position within the same sport. MRI has been shown to have higher sensitivity than ultrasound for diagnosing proximal hamstring tendinopathy. The difference in theory and application of interventions suggests the difference in the improvement. Neural tension tests such as the seated slump test can be used to determine if symptoms are due to lumbar spine or sciatic nerve involvement. 8600 Rockville Pike Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Players not wearing the shorts at any stage during the 1992 season had a higher rate of injury compared to those who wore the shorts for all of the season (32 vs 24 injuries/1000 playing hours), yet this difference was not significant.42 However, very few players wore the shorts for all of the season (n = 5).42 Interestingly, a significant difference existed in the rate of injury for players who occasionally wore the shorts, with more injuries occurring when players in this group were not wearing the shorts (57 vs 3 injuries/1000 playing hours).42, Randomized, controlled trials and well-designed cohort studies on the treatment of hamstring strain injury are lacking. (60), One study of 40 professional athletes with chronic proximal hamstring tendinopathy demonstrated that shockwave therapy had a greater improvement in pain scores, Nirschl phase rating scale and higher rate of return to sports than traditional conservative treatment of physical therapy and NSAIDs. The Puranen-Orava test is a standing test that actively stretches the hamstring when the hip is flexed to 90 degrees and the knee is extended fully and the foot is on a support 90 degrees to the standing body (FIGURE 1). (26) Progression to the next phase can occur when the athlete is able to walk normally without pain, jog at very low speeds without pain and able to perform pain-free isometric hamstring contraction with prone knee flexion at 90 degrees against submaximal resistance (5070%). Platelet-rich plasma as an effective treatment for proximal hamstring injuries. Similar biomechanical arguments may explain the higher rate of hamstring strain in black athletes, who reportedly frequently had anteriorly tilted pelvises.49. To perform the modified bent-knee stretch test, the patient is supine with the legs fully extended. Does the toe-touch test predict hamstring injury in Australian Rules footballers? Fluoroscopically Guided Peritendinous Corticosteroid Injection for Proximal Hamstring Tendinopathy: A Retrospective Review. Acute first-time hamstring strains during slow-speed stretching: clinical, magnetic resonance imaging, and recovery characteristics. Go assess hamstring flexibility are LBP patients, that active knee extension (AKE) and directly leg raise test are typical administered to subjects in the supine position and showed distinguished reliability for . ), the following tests are positive for hamstring tendinopathy or strain if the patient feels pain, heel is placed on an elevated surface and patient reaches for toes, with patient supine, hip and knee are maximally flexed and knee is slowly passively extended, with patient supine, hip and knee are maximally flexed and then the knee is rapidly fully extended, evaluation of the insertion site and quantify number of involved tendons and degree of tendon retraction, evaluate the sciatic nerve location (in chronic cases), tendinopathy will be seen as increased signal intensity in T1-weighted images, partial tears will have increased signal intensity on T2-weighted images, diagnosis confirmed by history, physical exam, and MRI, less active patients and those with significant medical comorbidities, acute hamstring strains in high level athletes, some low level studies have shown earlier return to play by 3-5 days in NFL players, partial avulsion that has failed nonoperative management for 6 months (persistent symptoms), 2 tendons with at least > 2 cm retraction in young, active patients, 80% return to preinjury level/sports at 6 months, high level of complications with surgery, up to 23% in some studies, higher complication rate with repair of chronic cases compared to acute (< 6 weeks), massage, ultrasound, electrical stimulation, most studies state 4 weeks, but should be extended if patient still significantly symptomatic, as symptoms resolve, abdominal, hip and quadriceps should be added to hamstring strengthening program to prevent reinjury, hamstrings should be strengthened to correct any hamstring-quadriceps strength imbalance, athlete kneels while heels are held on ground by an assistant; the athlete than leans forward until he is prone and then returns to original upright position, shown to reduce injuries by 50-70% in some studies, isolated targeting of specific hamstring muscles, long head of the biceps femoris and semimembranosus are more active during hip extension, semitendinosus and short head of biceps femoris more active during knee flexion, recommendation is to administer within 24-48 hours of acute injury. Definition and measurement of hamstring strain injury often varied, with no evidence presented for the technique used. Petersen J, Thorborg K, Nielsen MB, Skjodt T, Bolvig L, Bang N, et al. Conservative management for athletes with proximal hamstring tendinopathy that have been described in the literature include eccentric exercises,(17, 22, 27) soft-tissue mobilization,(22) shockwave therapy,(12) corticosteroid injections,(40, 63) and platelet-rich plasma injections. The athlete generally has no restriction of range of motion during this phase. Nonetheless, it would seem odd that no significant association with exposure time was identified if, conceivably, this resulted in increased exposure to the influence of other risks. Clinical principles in the management of hamstring injuries. Clinical risk factors for hamstring muscle strain injury: a prospective study with correlation of injury by magnetic resonance imaging. (21) Some studies have reported that almost 1 in 3 hamstring strains will recur, and many happen within the first 2 weeks of return to sport. (22) They states that prior to return to running after proximal hamstring tendinopathy, the athlete must have full range of motion and no pain with strength testing.(22). Titles and abstracts were reviewed by the authors for relevance and satisfaction of inclusion criteria. Hamstring peak torque was assessed during preseason in 6 professional and amateur Australian Rules football teams, however there was no difference between injured and noninjured players during the season.5 Similarly, hamstring power (watts) demonstrated no significant association with injury rate in the Icelandic professional football leagues.1 However, Yamamoto50 identified significantly less hamstring strength, as a proportion of body weight, in injured compared to noninjured Japanese collegiate athletes. Therefore, the 90/90 hamstring test is also known as the hamstrings length test. Inclusion in an NLM database does not imply endorsement of, or agreement with, Where low injury rates were described, which limited determining associations with potential risks, inadequate sampling may have contributed. Not a subscriber? Repetitive high-intensity sprint efforts and bending to gather the ball when running are characteristic of Australian Rules football.43 Emphasis on anaerobic interval training represents a change from traditional preseason training but may prevent injury via muscle conditioning and improved fatigue threshold.43, Functional interventions also appear to be effective in rehabilitation following hamstring strain injury.38 An important aspect of Sherry and Bests work is that it investigated athletes from various sports, and thus its results are potentially more applicable to a wider population than much of the existing literature.38 Of interest was the use of trunk stabilization exercises; because of the origin of the hamstrings at the pelvis. (23) The rehabilitation program used in the study was a progressive agility and trunk stabilization protocol. (40, 52, 61, 62). Foreman TK, Addy T, Baker S, Burns J, Hill N, Madden T. Prospective studies into the causation of hamstring injuries in sport: a systematic review, Local corticosteroid injection in sport: review of literature and guidelines for treatment. Nicholson LT, DiSegna S, Newman JS, Miller SL. Diagnosis can be made clinically with ecchymosis in the posterior thigh, tenderness over the hamstring muscles and avoidance of knee extension. (54) Another study by Silder et al randomized 29 athletes into 1 of 2 rehabilitation groups: a progressive agility and trunk stabilization program or a progressive running and eccentric strengthening program. Reliability and validity of three pain provocation tests used for the diagnosis of chronic proximal hamstring tendinopathy. Acute hamstring strains can occur with high-speed running or with excessive lengthening of the hamstrings. (12, 36, 40) It is a chronic, degenerative condition that is caused by mechanical overload and repetitive stretch. (24) All of the subjects also received a standard rehabilitation program. Athletes with hamstring strain injuries will typically describe sudden onset of sharp, stabbing or twinge-like posterior thigh pain. However, much of our knowledge of risk and treatment is based on traditional theoretical arguments with little empirical justification. (29, 39, 41) Hamstring eccentric exercises can be performed using hamstring curl machines, reverse cable curls, weight bearing hamstring curls on exercise ball, reverse plank, kneeling Nordic leg curl, standing single or double leg dead lifts. Methods: Why are older Australian football players at greater risk of hamstring injury? Accessibility Grade III injuries are severe, involve complete tears or rupture and result in significant loss of function. Acute hamstring strains can occur with high-speed running or with excessive hamstring lengthening. [2] PKET is used as a criteria for ACL return to play from phase 1 (wk 1-4) to phase 2 (week 4-8) . (55) Isolated resistance training of the affected hamstring muscle should be avoided. Hamstring injuries are one of the most common injuries in athletes. Given the interest in hamstring injury, additional studies may have been published after this review. Askling C, Saartok T, Thorstensson A. Benefits of ultrasound include decreased costs, ability to perform imaging in real time and provide guidance for injections. (26), Three physical examination maneuvers have been described for diagnosis of proximal hamstring tendinopathy. government site. Law M, Stewart D, Pollock N, Letts L, Bosch J, Westmorland M. Critical Review FormQuantitative Studies, Guidelines for Critical Review FormQuantitative Studies. While there was high agreement between reviewers for article critical appraisal using the McMaster Quantitative Review Guidelines instrument, it should be noted that there have been no published studies on the tools reliability and validity. 8600 Rockville Pike (26, 55) Progression to Phase III occurs when there is full strength of the hamstring without pain when performing 1 repetition of maximum isometric contraction with prone knee flexion at 90 degrees, and the athlete can jog forward and backward at 50% maximum speed without pain. Semitendinosus is one of the three muscles that make up the hamstrings muscle group, and it is located at the posterior and medial aspect of the thigh. (53) Ultrasound also provides the added benefit of serial evaluations for athletes to assess progress for return to play, particularly in settings where the team physician is skilled in ultrasonography to make the assessment in the training room. Hamstring strain injury is a noted problem within elite and recreational sport, often resulting in lengthy time off sport and frequent recurrence.9,11,31,37 The reported injury rate varies due to differing injury definitions and sporting populations; however, the reported prevalence in the various codes of football, to which most literature pertains, is generally 8% to 25%, with each injury resulting in a 2- to 6-week sporting absence.4,9,15,31,37,44,50 However, single-season prevalence in excess of 50% has been reported.2 Recurrence is also a prominent issue, with rates in excess of 30%, including rates of up to 60% to 70% in subsequent seasons.31,35,38,44, Despite much research interest, the risks for and best management of hamstring strains are not clearly understood. Fader RR, Mitchell JJ, Traub S, Nichols R, Roper M, Dan OM, et al. Orchard J, Best TM, Verrall GM. Hamid et al performed a randomized controlled trial where 28 patients with acute, grade II hamstring strains received either PRP with a rehabilitation program or a rehabilitation program alone. (11) Other examination findings include tenderness at the hamstring origin at the ischial tuberosity, and pain with active hamstring stretches. No potential conflict of interest declared. Additional articles were used as background material, but were not included in this reviews results. While efforts have been made to minimize their effect, several limitations are present in this review. Verrall GM, Slavotinek JP, Barnes PG, Fon GT, Esterman A. Witvrouw E, Danneels L, Asselman P, DHave T, Cambier D. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players: a prospective study, The Football Association Medical Research Programme: an audit of injuries in professional footballanalysis of preseason injuries. (60) Fader et al reported that out of 18 patients with chronic proximal hamstring tendinopathy treated with ultrasound-guided PRP injection, 10 patients reported 80% or greater improvement in pain at 6 months. Askling CM, Tengvar M, Saartok T, Thorstensson A. Acute first-time hamstring strains during high-speed running: a longitudinal study including clinical and magnetic resonance imaging findings. Subject gender reflected the sporting populations sampled, which typically revolved around the various codes of football: commonly Australian Rules (45.8%) and soccer (football) (20.8%). The notion of sport-specific risks is supported by the effectiveness of functional interventions to prevent injury. Evidence to support hamstring inflexibility as a significant risk is lacking. (26, 55) Ice can be used as needed for pain associated with exercise and rehabilitation. Grade II injuries include partial or incomplete tears and present with moderate loss of strength. Not a member? Askling CM, Malliaropoulos N, Karlsson J. Indeed, players with strength ratios greater than 0.9 displayed a significantly higher injury incidence (P = .02).5 With respect to hamstring/quadriceps muscle strength imbalances, significantly reduced peak torque ratios (60/s)representing increased quadriceps relative to hamstring strengthwere identified in footballers who suffered subsequent hamstring strain.34 The work of Yamamoto supports this; however, such strength imbalances were not predictive of future strain in the work of Bennell et al.5,10, Increased age appears to be a significant risk for hamstring strain injury, with 8 of 10 prospective cohort studies displaying significant associations between age and hamstring strain prevalence. The age at which the risk becomes significant potentially occurs between 23 and 25 years.13,14,16,35,49 Athletes older than 23 years were reportedly between 1.3 and 3.9 times more likely to suffer a hamstring strain,16,35 with athletes aged 25 years or older between 2.8 and 4.4 times more likely to suffer injury.13,14 As these figures suggest, the magnitude of risk appears to increases with age, with Verrall et al45 claiming that the risk increases by 30% annually. Epidemiology of National Football League training camp injuries from 1998 to 2007. (4, 26, 55) Type II hamstring strains occur in the setting of excessive lengthening of the hamstrings. (26, 55) They may also present with a stiff-legged gait because of avoidance of hip and knee flexion. While surgical techniques vary, the mean RTS time was similar, ranging between 5 and 6 months.22,27 Recurrences and failed repairs were minimal, with Klingele and Sallay22 reporting no reruptures and only 1 recurrence requiring a secondary operation in Lempainen et al.27 However, recurrences not requiring surgical intervention, if present, were not reported.27 Similarly, a retrospective cohort of American football players (gridiron) identified no recurrences when injured players were treated with intramuscular corticosteroid injection in addition to conventional treatment, but players were only followed during the course of their employment at one NFL club.28 Given the high squad turnover and player trading within the NFL,32 it is highly probable that unrecorded recurrences may have occurred in players while playing for another team. Levine WN, Bergfeld JA, Tessendorf W, Mooreman CT. Intramuscular corticosteroid injection for hamstring injuries: a 13-year experience in the National Football League, Cutting-edge muscle recovery: using antifibrosis agents to improve healing. Diagnosis can be made clinically with ecchymosis in the posterior thigh, tenderness over the hamstring muscles and avoidance of knee extension. An examination of the hip and lumbar spine and a complete neurological examination of the lower extremities should also be performed to identify any other potential causes of posterior thigh pain. Given the health benefits of regular exercise, encouraging and facilitating participation by appropriate prevention and reduction of injury risk must be considered worthwhile.33. Kingma JJ, de Knikker R, Wittink HM, Takken T. Eccentric overload training in patients with chronic Achilles tendinopathy: a systematic review. The available evidence for hamstring weakness as a risk is conflicting. The diagnostic and prognostic value of ultrasonography in soccer players with acute hamstring injuries. Moreover, whether minor wording changes to the instrument in this review make the tool any less applicable has not been studied. A summary of the critical appraisal scores is presented in Table 2. (4, 34, 42) Injuries can range from acute hamstring muscle strains and ruptures to chronic proximal hamstring tendinopathy. A lack of clear understanding of risks and the effectiveness of intervention may be factors in the high rate of hamstring strain incidence. De Vos RJ, Reurink G, Goudswaard GJ, Moen MH, Weir A, Tol JL. (35) Type I acute hamstring strains occur during high-speed running. Minor strains may go unreported to medical staff for fear of professional future or loss of income, while the effect of unreported preventive interventions is a potentially important confounder. Eccentric training for the treatment of tendinopathies. The https:// ensures that you are connecting to the Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JA, Bierma-Zeinstra SM, et al. Zissen MH, Wallace G, Stevens KJ, Fredericson M, Beaulieu CF. The type of acute hamstring strain and clinical factors such as time to walk without pain have been shown to correlate with time to return to play. Limitations in the available evidence, such as the previously common use of uncontrolled studies and retrospective designs, contribute to this lack of understanding. (11, 46) The bent-knee stretch test is performed with the patient in supine. Medicine and science in sports and exercise. Eccentric strengthening exercises are used for management of chronic proximal hamstring tendinopathy. For example, in a study of English football49 many players in the top league (EPL) were involved in a greater volume of games (domestic/European cup, international fixtures), possibly leading to increased fatigue. (26, 55), Phase II of rehabilitation involves increase in the intensity and range of motion of the exercises, initiation of eccentric resistance exercises, and neuromuscular training at faster speeds. Quadriceps flexibility is not widely reported as a significant risk, but the biomechanical explanation is similar to that of relative hamstring weakness. Particularly, decreased hamstring strength relative to quadriceps strength appears to increase the risk for injury.34,50 The hamstrings eccentrically decelerate the lower limb during the swing phase of running before extending the hip to achieve propulsion, while their braking function is also obvious in kicking sports; these are biomechanical demands that are frequently noted as the mechanism of injury.4,5,16,37,49 Should quadriceps strength be increased relative to hamstring strength, the capacity to exert increased lower limb swing force is conceivably greater, thereby placing increased demands on the hamstrings to decelerate the limb. All patients who received PRP returned to play in 4.5 months. The average time to return to full practice was 7.6 days, ranging from 0 to 24 days, and 49 players missed no games. With the increasing commercialization of professional sport, costs to clubs and individuals are no longer limited to those incurred by rehabilitation.40,48,4 Despite much research interest, knowledge of how to prevent and treat hamstring strains is incomplete, as evidenced by the high rate of injury and recurrence reported in the literature. 1296. Before sharing sensitive information, make sure youre on a federal (1, 26, 55) They may describe an audible pop, which has been reported primarily in type II (overstretch) hamstring strains. (49) They reported no significant difference in time to return to sport (median 42 days in both groups) or re-injury rate (16% in PRP group versus 14% in placebo group). A systematic literature review was conducted. Sherry M. Examination and treatment of hamstring related injuries. A palpable defect in the muscle or musculotendinous unit may be appreciated in athletes with complete ruptures. Studies of adult athlete populations (older than 18 years) pertaining to hamstring strain incidence, prevalence, and/or intervening management of hamstring strain injury were included. Longitudinal study comparing sonographic and MRI assessments of acute and healing hamstring injuries. 2023 Lineage Medical, Inc. All rights reserved. The article focuses on diagnosis, treatment and return to play for hamstring strains and proximal hamstring tendinopathy in the athlete. the contents by NLM or the National Institutes of Health. Reliability and validity of the outcome measures used was typically not addressed. purpose: to assess the range of active knee extension in a position of hip flexion, as required in running and kicking. Poor aerobic capacity is involved with general fatigue yet had no significant association with hamstring strain.1,34 If fatigue is a factor, it must be intrinsic to the muscle itself. Meta-analysis was considered, but inadequate sample description and proposed differences between professional and amateur athletesand those of different sportsprecluded this. Professional or amateur athletes older than 18 years, Aim 2: Any reported intervention for the prevention or treatment of hamstring strain injury, Aim 1: Adult athletes not suffering hamstring strain injury, Aim 2: Any reported management comparison (eg, no intervention, usual care, X versus Y), Aim 1: Incidence/prevalence of hamstring strain injury and/or recurrence, Aim 2: Return to sport (RTS) time, incidence/prevalence of hamstring strain injury recurrence, hamstring, muscle strain, prevention, management, systematic review. Smaller studies looking at corticosteroid and PRP injections have had mixed results. Assessment of physical examination and magnetic resonance imaging findings of hamstring injury as predictors for recurrent injury. Of the 7 articles that underwent duplicate appraisal, differences in item classification for all articles existed in less than 10% of cases, and thus the inter-rater agreement was deemed appropriate. Koulouris G, Connell D. Hamstring muscle complex: an imaging review. High-speed running type or stretching-type of hamstring injuries makes a difference to treatment and prognosis. Federal government websites often end in .gov or .mil. FOIA Cohen S, Bradley J. Home / Hamstring Tightness Assessment In patients who have irritation of the bursa around the knee with patellofemoral pain, it is important to determine the amount of relative hamstring tightness. There have been mixed results in the literature regarding the effectiveness of platelet-rich plasma (PRP) for acute hamstring strains. An official website of the United States government. However, imaging findings generally have not been shown to correlate with prognosis of return to play. Levine et al performed a retrospective review of 58 professional NFL players who were treated with corticosteroid injections after acute hamstring strains. Slavotinek JP, Verrall GM, Fon GT. Brooks JHM, Fuller CW, Kemp SPT, Reddin DB. Why age is a risk remains contentious; however, age-related muscle changes and prolonged exposure to additional risks have been proposed.16,35, Height displayed no significant association with the rate of initial or recurrent hamstring strain injury in any study.1,14,16,34,35,44,45 In contrast, race and ethnicity were strongly associated with injury, with black athletes significantly more likely to suffer hamstring strains.45,49 Notably, Aboriginal Australian Rules footballers were 11.2 times more likely to suffer hamstring strain than non-Aboriginals (95% CI: 2.1-62.5).45 A study of the English professional football leagues (English Premier League [EPL]-League 2) suggests that this is not specific to any one nationality or ethnic group but to all players of black racial background.49, The evidence for weight and body mass index (BMI) as risks for hamstring strain injury is conflicting. DSTM was more effective than PNF stretching in reducing hamstring tightness and pain. The hamstring muscles have a common origin on the lateral aspect of the ischial tuberosity. Careers, Unable to load your collection due to an error. The patients in the PRP group had a statistically significantly faster return time to return to play (26.7 +/ 7.0 days versus 42.5 +/ 20.6 days) as well as significantly lower pain severity scores than the rehabilitation group. (55) However, the early use of NSAIDs for acute hamstring strains is controversial, as prior studies have not demonstrated benefit. Diagnosis can be confirmed with MRI. Articles were limited to full-text randomized, controlled studies or cohort studies. Current thinking regarding risk and management may not be incorrect, but the underlying evidence has notable limitations and is inappropriately designed to produce conclusive answers. Warren P, Gabbe BJ, Schneider-Kolsky M, Bennell KL. Hamstring strains in athletes: diagnosis and treatment. The 90/90 test, also known as the Active Knee Extension (AKE) Hamstring Flexibility Test, measures hamstring flexibility, particularly when the hip is flexed. Hip flexion active ROM was measured via . Most of the appraised literature pertained to studies of male footballers, thus the extent to which results can be extrapolated to other sporting populations, particularly female athletes, is uncertain. Acute proximal hamstring rupture. Standing jump and counter-movement jump test performance in a group of professional footballers demonstrated no significant association with the rate of injury,1 while the rate of recurrence was significantly different between 2 groups of Australian Rules footballers, despite both groups displaying no significant difference with respect to any functional measure (hop height, hop distance, sprint time).38 There was no evidence to suggest that playing conditions, including ground condition and air temperature, were significant risks.35. Hamstring injuries of the hip. A summary of studies is provided in Table 1. Hamid MS, Yusof A, Mohamed Ali MR. Platelet-rich plasma (PRP) for acute muscle injury: a systematic review. Predictors of hamstring injury at the elite level of Australian football, A pilot, randomised, controlled trial of eccentric exercise to prevent hamstring injuries in community-level Australian football. official website and that any information you provide is encrypted The 90/90 hamstring test is used to assess the hamstrings muscles flexibility i.e tightness in the hamstrings muscle. A thorough history and examination is important to determine the appropriate diagnosis and rule out other causes of posterior thigh pain. Theoretically, adequate neuromuscular control of the trunk and pelvis is required to both optimize function and prevent inappropriate length-tension relationship changes.38 This is consistent with previous research. Players, especially professional athletes in kicking sports, may be undertaking much quadriceps strengthening, which may influence their hamstring strain risk. For the purpose of this review, management was considered to refer to any intervention aimed at influencing the hamstrings, whether it be preventive or pertaining to acute management and rehabilitation. There is higher percentage of prevalence of hamstring tightness in right lower extremity *2+. MRI appearance of the proximal hamstring tendons in patients with and without symptomatic proximal hamstring tendinopathy. In addition, where retrospective designs were used, whether variables were risks or outcomes is debatable.4 Studies of professional athletes have intrinsic limitations. Current evidence is inconclusive regarding most interventions for hamstring strain injury, while the effect of potentially modifiable risks is unclear. Rehabilitation of proximal hamstring tendinopathy utilizing eccentric training, lumbopelvic stabilization, and trigger point dry needling: 2 case reports. Each author undertook independent appraisal of a random selection of articles after establishing inter-rater agreement of appraisal. Progressive ability and trunk stabilization exercises should incorporate more sport-specific drills and dynamic agility exercises. HHS Vulnerability Disclosure, Help Enroll in our online course: http://bit.ly/PTMSK DOWNLOAD OUR APP: iPhone/iPad: https://goo.gl/eUuF7w Android: https://goo.gl/3NKzJX GET OUR ASSESSMENT B. This clinical test is applied in the clinic to check the tightness of hamstrings. Magnetic resonance imaging clinics of North America. Hamilton et al performed a study on 90 professional athletes with grade I or grade II hamstring strains confirmed on MRI, randomizing them to either receive PRP, platelet-poor plasma or no injection. Studies investigating corticosteroid and platelet-rich plasma injections have mixed results. Wetzel RJ, Patel RM, Terry MA. Eccentric strengthening exercises are used for management of proximal hamstring tendinopathy. The endpoint for the AKE test was determined by the criterion of pain in the hamstring muscles. (9, 21) While considerably shorter than the aforementioned studies on type I and II injuries, these studies involved different sports and also did not take into account return to pre-injury level of performance. After collectively appraising 5 articles to establish standardization between reviewers, each author undertook independent critical appraisal of a random selection of included articles. To present the current best evidence for hamstring strain injury risk factors and the management of hamstring strain injury. Hamilton B, Tol JL, Almusa E, Boukarroum S, Eirale C, Farooq A, et al. Further high-quality prospective studies into potential risks and management are required to provide a better framework within which to target interventions. Seven studies of footballers from Australia (Australian Rules) and Scandinavia examined this, with only 1 study not identifying a significant association between injury history and future strain incidence.34 Most studies deemed that athletes with a history of hamstring strain were between 2 to 6 times more likely to suffer subsequent strains.1,5,14,18,35,45 Most recurrences happened soon after RTS (history of hamstring strain within previous 8 weeks: relative risk [RR], 6.33; [95% confidence interval (CI): 5.21-7.70]35), however, the risk remained significant over time.1,5,14,18 Footballers remained approximately 3 times as likely to suffer a recurrence even beyond a year from the initial injury.14,18 While most strains involved the biceps femoris, the muscle injured did not predict recurrence.44,49 Similarly, the size and severity of the initial injury was not significantly associated with recurrence within the same season.24 However, athletes with larger strains had a significantly higher risk of recurrence within 2 seasons.49, Other lower limb injuries were also associated with an increased risk of hamstring strain, supporting arguments of the role of the hamstrings as part of a larger kinematic chain.35,45 Australian Rules footballers with a previous calf injury were 1.37 times more likely to suffer hamstring strain (95% CI: 1.08-1.76),35 while athletes who had sustained a previous substantial knee injury (P = .009) or who had a history of osteitis pubis (P = .023) were also at greater risk.45 Hamstring strain risk with respect to back injury history was also investigated but no significant association was identified.45, Hamstring flexibility demonstrated no significant association with the rate of injury in 4 prospective cohort studies.1,13,16,34 Only one study, of footballers in the Belgian professional leagues, reported a significant association, with players who suffered hamstring strains during the 1999-2000 season having significantly less flexibility at preseason baseline testing (P = .02).47 However, methods of assessing hamstring flexibility have been criticized for being unable to differentiate from lumbo-pelvic flexibility.4 Recognizing the relationship between these 2 motion segments, combined hamstring and lumbo-pelvic flexibility has been investigated yet demonstrated no significant risk.4,14 Similarly, neural flexibility displayed no significant association with injury.14,16, The flexibility of other thigh muscles, however, appears to be of more importance than that of the hamstring group. Athletes with proximal hamstring tendinopathy often do not report a specific inciting event; instead they develop the pathology from chronic overuse. and transmitted securely. Higher levels are likely to be faster and more physically demanding, potentially explaining this finding. (17) There have been case reports in the literature demonstrating improvement of proximal hamstring tendinopathy with eccentric exercises in athletes. To enable comparison of appraisal, raw scores were expressed as a percentage of the total score possible. Semitendinosus and the long head of the biceps femoris share a conjoined tendon originating from the lateral facet, whereas the semimembranosus origin is deeper, 67 although anatomical variation is reported. They are especially common in athletes who participate in sports that require sprinting, such as track, soccer, and basketball. Debate exists as to whether this is because of inadequate rehabilitation and premature RTS, or whether an intrinsic risk is created by the initial injury.1,37,42,45,46 Premature RTS arguably places the athlete at higher risk, but even in the presence of thorough rehabilitation, with corresponding functional improvement, recurrence remains high.5,42 The argument exists, therefore, that the hamstrings are at risk because of scar tissue formation and reorganization secondary to initial strain.7,9,29,45 However, other studies suggest that this may not be the predominant factor, citing the lower levels of recurrence for other muscle strains.46, Functional performance measures had no significant association with either initial or recurrent hamstring strain injury. Achilles tendonitis: are corticosteroid injections useful or harmful? (5) Shorter times to return to play after acute hamstring strain have been reported in studies on NFL and professional rugby players, ranging from a mean of 8 to 25 days lost from full training and competition. Much of the existing literature linking hamstring tightness with strain incidence has been retrospective, posing questions as to whether muscle tightness is a predisposing factor to or a consequence of injury.4 However, hamstring inflexibility cannot be ruled out as a risk factor; flexibility was often assessed via sit-and-reach and straight leg raise (SLR) tests, with such tests criticized for being unable to differentiate hamstring from lumbo-pelvic flexibility or identify contralateral muscle differences.13,16,20,34,47 The concept of a critical degree of inflexibility also poses questions, as authors have noted that the athletes studied were relatively flexible, likely due to regular stretching as part of their training, and were thus studying a group in whom inflexibility was not an issue.4, The role of muscle tightness in hamstring strain appears most likely related to biomechanical factors. Tight hamstrings may contribute to the range . (48) Moen et al also report no correlation of MRI findings in grade I and grade II hamstring injuries and time to return to play. (16, 57) However, other studies have shown that the severity of hamstring injuries based on MRI and baseline MRI findings of initial injuries do not predict reinjury. The test measures the angle of knee flexion with a pendulum goniometer after active knee extension with the hip stabilized at 90 degrees flexion. (5) These types of hamstring strains are more common in activities such as dancing, slide tackling and high kicking that combine hip flexion with knee extension. (12, 22, 35) Symptoms can be exacerbated with repetitive eccentric hamstring contraction, forward flexion of the trunk and with running. There is no significant use for x-ray imaging in the evaluation of acute hamstring strain unless an ischial avulsion injury is suspected. Clinically with ecchymosis in the posterior thigh pain imaging findings generally have not been to... 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